I.C. Chetter

Percutaneous transluminal angioplasty for intermittent claudication: Evidence on which to base the medicine

OBJECTIVESnThis study aims to assess the impact of PTA on the quality of life (QoL) of claudicants and to analyse which patients and which arterial lesions derive the most benefit.nnnDESIGNnA prospective observational study.nnnMATERIALSnOne hundred and seventeen claudicants undergoing PTA were studied; 35 patients had bilateral disease, whilst 82 had unilateral disease and underwent PTA to a solitary iliac lesion, solitary superficial femoral or a iliac lesion above a diseased superficial femoral artery in 24, 39 and 19 cases, respectively.nnnMETHODSnPatients completed the Short Form 36 (SF36) and EuroQol (EQ) QoL assessment instruments prior to and at 1, 3, 6, and 12 months following intervention. The SF36 produces a QoL profile, whilst the EQ produces two QoL indices.nnnRESULTSnClaudication has a deleterious effect on QoL, especially in patients with multi-segment disease. PTA results in an immediate and lasting improvement in the QoL of claudicants. Unilateral claudicants undergoing PTA to a solitary iliac lesion demonstrate the most marked QoL benefits and 12 months post PTA report a QoL approaching that of an age-matched population. Patients with bilateral claudication undergoing unilateral PTA and unilateral claudicants undergoing PTA to a solitary SFA lesion demonstrate some QoL benefits, but at 12 months post PTA do not approach the QoL scores of an age-matched population. Unilateral claudicants undergoing iliac PTA above a diseased SFA demonstrate minimal QoL changes.nnnCONCLUSIONSnThese results should influence decision making in the management of claudication and it may be possible to prioritise PTA waiting lists to ensure patients with greatest potential benefit are treated with most urgency.

The Hand Arm Vibration Syndrome: A Review

Since its first description over eight decades ago, the hand arm vibration syndrome-- vibration white finger as it was previously known--has become one of the most common prescribed diseases in the industrialized world. This article is intended to provide a broad review of existing evidence and knowledge regarding a disease which, for medicolegal reasons, demands attention from all medical personnel. Detailed discussion is presented regarding: the multifactorial aetiology of the syndrome; suggestions for clinical assessment, laboratory investigations and classification of disease severity; and strategies for the prevention and treatment of the syndrome.

ALLOGENEIC VERSUS AUTOLOGOUS BLOOD DURING ABDOMINAL AORTIC ANEURYSM SURGERY

OBJECTIVESnTo determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay.nnnDESIGNnA prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery.nnnMETHODSnFifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device.nnnRESULTSnThe haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fishers exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%).nnnCONCLUSIONSnCell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.

An Introduction to Quality of Life Analysis: The New Outcome Measure in Vascular Surgery

any population sample or illness group, and thus are applicable to a wide range of health problems. The majority of generic instruments reflect the WHO definition of health by assessing the theoretically or empirically distinct aspects of health, commonly termed domains or dimensions. Domains frequently measured by generic instruments include: physical functioning (mobility, self care), emotion or mood (anxiety, depression, vitality), social functioning (social activities, contact and isolation), role performance (work, housework), pain, and other commonly performed daily activities, e.g. sleep and sexual functioning. These generic instruments can be further subdivided into those which provide a single global score or health index and those which provide a number of domain scores or health profile. Some instruments provide both. The main advantage of a single index is that it can be incorporated into quality adjusted life year (QALY) calculations and can thus be used in cost effectiveness/utility analyses. This broad approach to QL analysis facilitates comparisons between different disease groups and different centres; however, responsiveness may suffer.

The regulation of neutrophil activation and adhesion during femorodistal bypass surgery

OBJECTIVEnTo determine the effect that revascularising chronic critically ischaemic legs has no neutrophil activation and adhesion.nnnDESIGNnProspective clinical study.nnnSETTINGnUniversity Hospital.nnnMATERIALSnTwenty-five patients, 16 men and nine women undergoing femorodistal surgery.nnnCHIEF OUTCOME MEASURESnVenous blood assays for neutrophils expression of CD11b, neutrophil adhesion, and the plasma concentration of the shed endothelial adhesion receptor, soluble intracellular adhesion molecule 1 (sICAM-1). Urinary microalbuminaemia was measured and expressed as an albumin/creatinine ratio (ACR), as a marker of vascular permeability and plasma neutrophil elastase as evidence of neutrophil activation. Venous blood was taken preoperatively, during surgery and for the first 7 days postoperatively.nnnMAIN RESULTSnNeutrophil CD11b expression fell following reperfusion of the limb (21.4 mcf to 9.7 mcf, p < 0.02 Mann Whitney U-test) as did neutrophil adhesion (preop. 75% adhesion, postop. 28% p < 0.01). However, the plasma elastase levels rose from 95 micrograms/l to 345 micrograms/l at 4 h and the ACR increased from 5.3 mg/ml to 304.2 mg/ml. The concentration of sICAM-1 fell following reperfusion (p < 0.04).nnnCONCLUSIONnThe change in CD11b, sICAM-1 and adhesion may represent a normal immunological response to ischaemia/reperfusion.

How effective is acute normovolaemic haemodilution in femoro-distal bypass surgery?

BACKGROUNDnRecent guidelines have emphasised the use of autologous blood in the surgical setting. The aim of this study was to analyse the efficacy and efficiency of acute normovolaemic haemodilution (ANH) as a blood conservation intervention in patients undergoing elective femoro-distal surgery for critical limb ischaemia.nnnMETHODSnForty patients were studied prospectively. The volume of the blood collected was derived as follows: Blood volume removed = patients blood volume (initial haematocrit - final haematocrit/average haematocrit) where final haematocrit is 30% and patients blood volume is 70 and 65 ml/kg for a man and a woman, respectively.nnnRESULTSnTwenty-five patients were suitable for ANH and 15 patients were excluded because of poor ventricular function, anaemia or renal disease. Nine of the 25 patients (44%) had <500ml of surgical blood loss and would have avoided homologous blood transfusion (HBT). Four of the patients lost >2000ml of blood and could not avoid HBT through ANH. Twelve patients had moderate blood loss (950-1400 ml), with eight of these patients requiring transfusion. Four patients avoided exposure to homologous blood.nnnCONCLUSIONnANH is in evolution and as a single blood conservation intervention, contributes only modestly to blood conservation.